Association of Interactive Reminders and Automated Messages With Persistent Adherence to Colorectal Cancer Screening: A Randomized Clinical Trial | Cancer Screening, Prevention, Control | JAMA Oncology | JAMA Network
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Figure.  Consort Flow Diagram
Consort Flow Diagram

FIT indicates fecal immunochemical test.

Table.  Effectiveness of Telephone and SMS Reminders on Rate of FIT Pickup and Return
Effectiveness of Telephone and SMS Reminders on Rate of FIT Pickup and Return
1.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.  JAMA. 2016;315(23):2564-2575.PubMedGoogle ScholarCrossref
2.
Richardson  LC, Tai  E, Rim  SH,  et al; Centers for Disease Control and Prevention (CDC).  Vital signs: colorectal cancer screening, incidence, and mortality—United States, 2002-2010.  MMWR Morb Mortal Wkly Rep. 2011;60(26):884-889.PubMedGoogle Scholar
3.
Liang  PS, Wheat  CL, Abhat  A,  et al.  Adherence to competing strategies for colorectal cancer screening over 3 years.  Am J Gastroenterol. 2016;111(1):105-114.PubMedGoogle ScholarCrossref
4.
Wong  MC, Lam  TY, Tsoi  KK,  et al.  A validated tool to predict colorectal neoplasia and inform screening choice for asymptomatic subjects.  Gut. 2014;63(7):1130-1136.PubMedGoogle ScholarCrossref
5.
Wong  MC, Ching  JY, Lam  TY,  et al.  Prospective cohort study of compliance with faecal immunochemical tests for colorectal cancer screening in Hong Kong.  Prev Med. 2013;57(3):227-231.PubMedGoogle ScholarCrossref
6.
Power  E, Miles  A, von Wagner  C, Robb  K, Wardle  J.  Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation.  Future Oncol. 2009;5(9):1371-1388.PubMedGoogle ScholarCrossref
Research Letter
September 2017

Association of Interactive Reminders and Automated Messages With Persistent Adherence to Colorectal Cancer Screening: A Randomized Clinical Trial

Author Affiliations
  • 1Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
  • 2J. C. School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
  • 3State Key Laboratory for Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
  • 4Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
JAMA Oncol. 2017;3(9):1281-1283. doi:10.1001/jamaoncol.2017.1062

The US Preventive Services Task Force recommends annual fecal immunochemical test (FIT) as one of the colorectal cancer (CRC) screening tests.1 Adherence to yearly FIT is crucial to programmatic success.2 However, longitudinal adherence is low and strategies to improve persistent adherence are needed.3 We evaluated the effectiveness of interactive telephone calls vs automated short message service (SMS) on improving adherence to FIT screening compared with usual care.

Methods

We conducted a prospective randomized parallel group study, with the setting previously described.4 The trial was registered on Clinicaltrials.gov (NCT02815436). Asymptomatic patients with negative FIT results in their first screening round from April to September 2015 due for annual screening in 2016 were eligible. Patients who could not understand telephone or SMS, or did not have mobile phones were excluded. Participants were randomized by a computer-generated sequence with an allocation ratio of 1:1:1. In the control group, participants were told in 2015 that they should visit the screening center for annual FIT pickup at the same calendar month of 2016. In the SMS group, subjects received a 1-way SMS, highlighting importance of CRC screening, and notifying date and location of FIT pickup on their mobile. In the telephone group, participants received a call from a trained health care physician with the same message as the SMS, but an interactive conversation was permitted. The interventions were delivered 1 month before the expected date of participant return for second round of screening. The Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee approved the study and participant consent was waived because the interventions were an extension of the screening services. The trial protocol is provided in the Supplement.

Outcomes were rate of FIT pickup within 1 month of a patient’s anticipated return, and rate of FIT return within 2 months of anticipated return. Six hundred patients provide 80% power (at 5% α level) for detecting an 11% increase in FIT return rate in the intervention groups compared with control, which was assumed to have a FIT return rate of 70%.5 Associations between study groups and outcomes were examined by backward stepwise, binary logistic regression. Subgroup analysis for sex, marital status, household income, and educational level were performed, because these factors were previously found to be associated with screening adherence.6

Results

Of 621 patients, 207 were randomized to the control group, 209 to the SMS group, and 205 to the interactive telephone group (Figure). No statistically significant differences were noted among the groups for participant and clinical characteristics, including age, sex, and sociodemographic variables. The FIT pickup rate was 62.3%, 78.5%, and 89.8% for the control, SMS, and telephone groups, respectively (P < .001) (Table). Delayed pick up of FIT (ie, 1 month after the anticipated return date) occurred in 10.6%, 6.7%, and 3.4% of the corresponding groups, respectively (P = .02). The FIT return rate was 69.1%, 82.8% and 91.2%, for the respective groups (P < .001). The FIT pickup and return rates were significantly higher in the telephone group compared with the SMS group. Both interventions were more effective for FIT pickup and return than control, with similar unadjusted and adjusted odds ratios. The findings remained significant on subgroup analysis.

Discussion

Nonadherence to longitudinal FIT screening contributes to CRC mortality.2 Telephone calls and SMS conferred a 5.2- and 2.4-fold higher likelihood of FIT return. Our findings should, however, be interpreted with caution because they could be sensitive to the timeframe when adherence was measured. These strategies acted on the predisposing and reinforcing factor components of the PRECEDE-PROCEED model. Telephone calls were superior to automated 1-way SMS, implying personal interaction with health care professionals enhances adherence. Screening programs in other settings with low adherence should consider telephone-based or SMS strategies to maximize the mortality benefits of screening. Since colonoscopy continues to be the gold-standard screening test in many developed countries and its adherence barriers may be different, the effectiveness of these strategies on enhancing colonoscopy attendance should be evaluated in future studies.

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Article Information

Corresponding Author: Martin C. S. Wong, MD, MPH, School of Public Health, Chinese University of Hong Kong, 4/F, Princes of Wales Hospital, Sha Tin, Hong Kong 852 (drwong_martin@yahoo.com.hk).

Accepted for Publication: March 2, 2017.

Correction: This article was corrected online on June 15, 2017, to fix an error in one of the author’s degrees listed in the byline. Where it previously read Francis K. L. Chan, MD, PhD, it now reads Francis K. L. Chan, MD, DSc.

Published Online: May 18, 2017. doi:10.1001/jamaoncol.2017.1062

Author Contributions: Dr M. Wong had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: M. Wong, Ching, Wu, Chan.

Acquisition, analysis, or interpretation of data: M. Wong, Lam, J. Wong.

Drafting of the manuscript: M. Wong, Chan.

Critical revision of the manuscript for important intellectual content: M. Wong, Ching, Lam, J. Wong, Wu.

Statistical analysis: M. Wong.

Obtained funding: M. Wong, Chan.

Administrative, technical, or material support: Ching, Lam, J. Wong, Chan.

Study supervision: M. Wong, Ching, Wu, Chan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This project was funded by the Hong Kong Jockey Club Charities Trust.

Role of the Funder/Sponsor: The Hong Kong Jockey Club Charities Trust had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We are grateful for the advice offered by Joseph J.Y. Sung, MD, Institute of Digestive Disease, The Chinese University of Hong Kong, and the administrative and logistic support by Victor C.W. Chan, BSc, Arthur K.C. Luk, BBA, and Zero Hui, BSS, Institute of Digestive Disease, The Chinese University of Hong Kong. None received financial compensation for their work.

References
1.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.  JAMA. 2016;315(23):2564-2575.PubMedGoogle ScholarCrossref
2.
Richardson  LC, Tai  E, Rim  SH,  et al; Centers for Disease Control and Prevention (CDC).  Vital signs: colorectal cancer screening, incidence, and mortality—United States, 2002-2010.  MMWR Morb Mortal Wkly Rep. 2011;60(26):884-889.PubMedGoogle Scholar
3.
Liang  PS, Wheat  CL, Abhat  A,  et al.  Adherence to competing strategies for colorectal cancer screening over 3 years.  Am J Gastroenterol. 2016;111(1):105-114.PubMedGoogle ScholarCrossref
4.
Wong  MC, Lam  TY, Tsoi  KK,  et al.  A validated tool to predict colorectal neoplasia and inform screening choice for asymptomatic subjects.  Gut. 2014;63(7):1130-1136.PubMedGoogle ScholarCrossref
5.
Wong  MC, Ching  JY, Lam  TY,  et al.  Prospective cohort study of compliance with faecal immunochemical tests for colorectal cancer screening in Hong Kong.  Prev Med. 2013;57(3):227-231.PubMedGoogle ScholarCrossref
6.
Power  E, Miles  A, von Wagner  C, Robb  K, Wardle  J.  Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation.  Future Oncol. 2009;5(9):1371-1388.PubMedGoogle ScholarCrossref
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